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vcy IJ uu ua,00a rnv LUtst 7` ^S66$1$ P.1 <br /> SAN JOAQUIN COUNTY <br /> EN V TRGNM ENTAL HEALTH DEPAP TM ENT <br /> 600 Fist NSain Street,Stocklen,CA 95202-3029 <br /> rdephome:(atKl)468-3420 Fax:(209)458-3433 Web.www sieov.or /q eE%d <br /> RETURN TO COIVIPL _kRCF_ CEPTilurATION <br /> Any MINOR violations noted in the"Notiaeto•.Clomply"in the attached Inspection Report must be <br /> corrected within 30 dans of receipt of th'istitisp,ectioh:This certification form must be submitted to the <br /> 1=..v.mnm.-.r.ta1 NMIth 1J /.7t>?1P�Ii 1r1HU.l aauresa ul.gw coy ur u.;> rL.,:. widatu '��i Jnya of ��+-:,aLurtr,o <br /> Inspection Report. <br /> All corrections to other violations noted In the attacned Inspection Keport(TR)or Continuation Funn,or <br /> disputes to any violations, arc to be submitted using this certification and retrxned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> tic current hourly rate. <br /> For this certification to be Complete the operator of the site must include: <br /> a A statement documenting what corrective actions were taken or will betaken for each violation <br /> e Copies of sample resultslmanifestsltraining records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> a Operator's certification/ <br /> Inspection Date:�71 t Inspected By: A i 1 S <br /> Facility Address: ?cF-; 1--<.). EPA ID#: CaLOc)o 293 rD <br /> I certify under penalty of law that: <br /> 1. 1'iave corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection_date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and l believe the information to be true, accurate,and complete: <br /> Photos Paperwork.�e Statement <br /> 3. lam authorized to submit this certification or behalf of the Respondent. <br /> 4. I am aware that there aze significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: "7c'E R !21,q 9176/t1 Title: 17 tST til 0-7 Ilii 9-njA f7 <br /> Signature: Date: / I i <br /> EHD 22-02-005 Rev I V07 <br /> l'd L£9£bb960Z1 egnj oad dlZZo ll 90 inf <br />